STOWE, VERMONT—Advance planning for rescue therapy can prevent the need for a patient with headache to visit the emergency room, Rebecca Burch, MD, stated at the 23rd Annual Winter Headache Symposium of the Headache Cooperative of New England.

Physicians have several options that are supported by evidence for treating patients who come to the emergency room, said Dr. Burch, Instructor of Neurology at Brigham and Women’s Hospital in Boston. The choice of rescue therapy may be a matter of the physician’s preference, but neurologists should be cautious when using steroids repeatedly for one patient, she added.

Infusion Centers May Be Preferable to Emergency Rooms
“Most patients who get symptomatic treatment of any kind for headache should have rescue therapy considered at least once,” said Dr. Burch. Rescue therapies also should be considered when symptomatic therapies are intermittently or partially ineffective. “The most common indication for rescue treatment is when a severe headache is accompanied by nausea or vomiting that prevents the use of oral treatments. Nonoral treatments may be necessary as a backup,” said Dr. Burch.

At-home rescue therapy generally is the first option, but when it does not work, urgent settings, including the emergency department, may be more appropriate. Emergency rooms are “a terrible place for headache patients,” because they are loud, have bright lights, and require patients to wait for long periods, said Dr. Burch. Emergency physicians may be skeptical about the headache’s severity and may administer nonspecific treatments, she added.

An infusion center can serve as an intermediate site between a patient’s home and the emergency room, and these centers are becoming more common as part of headache treatment models. Securing the commitment of trained nurses “is extremely important” for infusion centers’ success, said Dr. Burch. Also crucial is understanding that the appropriate length of stay is different there than at a typical infusion center. “Migraineurs don’t really want to come in and be rushed out again. They often want a chance to get away from it all and relax in a comfortable environment with people taking care of them,” said Dr. Burch.

Dihydroergotamine Is the “Workhorse” Rescue Treatment for Migraine
Among the nonsteroidal anti-inflammatory drugs (NSAIDs) appropriate for rescue therapy, ketorolac and indomethacin have the most supporting data. Ketorolac is available in tablets, but parenteral administration may work better because it crosses the blood–brain barrier more easily, said Dr. Burch. Indomethacin, which is available in a suppository, is more effective if not administered orally, she added. Because NSAIDs entail a risk of gastrointestinal bleeding, physicians should exercise caution when administering them concurrently with steroids.

The most common dopamine antagonists used as rescue therapy are promethazine, metoclopramide, and prochlorperazine, which are not sedatives and entail little risk of extrapyramidal symptoms. Although chlorpromazine and haloperidol are more effective for migraine, they have many potential side effects and usually are restricted to monitored or in-patient settings.

Dihydroergotamine (DHE) is “the workhorse of acute and urgent emergency room treatment” for migraine, said Dr. Burch. The typical dose for patients who have never taken the drug is 0.5 mg. If the patient tolerates DHE, he or she should receive another 0.5 mg in 30 to 60 minutes, followed by 1 mg every eight hours. Nausea is the major side effect of DHE, so administering an antiemetic such as metoclopramide 15 to 30 minutes in advance may be advisable, according to Dr. Burch.

Drugs that stabilize the cortex, such as magnesium, also can be effective rescue therapies. Magnesium is “excellent” for pregnant women with migraine because it is safe to administer during pregnancy, although it can be caustic to peripheral veins, said Dr. Burch. Valproic acid can be given in one 250- to 500-mg dose or in a dose of 500 to 1,000 mg over 10 minutes. Levetiracetam has proponents as a rescue therapy for headache, although few data support it, Dr. Burch observed.

Steroids may be the most common rescue therapy for headache. Neurologists may administer 4 mg of dexamethasone twice per day for four days. Methylprednisolone is available in a prefilled dose pack that is popular for its convenience. “Prednisone is kind of an old standby,” added Dr. Burch. To date, no research has compared one steroid to another for the treatment of headache. A patient who takes steroids repeatedly or for long periods is at risk of avascular necrosis, cautioned Dr. Burch.

Emergency departments frequently use opioids for headache, but they are not specific to migraine. Repeated opioid use can cause central sensitization and hyperalgesia syndrome. Of all opioids used to treat migraine, the most data exist for meperidine, which is rarely used because it can cause toxicity.

—Erik Greb
Senior Associate Editor

Planning Rescue Treatment Early Can Prevent Emergency Room Visits for Headache